Help Request
* = a required field
Are you a...
Parent/caregiver calling about a child/young adult
Professional calling about a child/young adult
Professional calling about general information
Contact Info
First Name
Last Name
Mobile Phone
Email
Street
City
State
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip
Borough
Please select...
Bronx
Brooklyn
Manhattan
Queens
Staten Island
Other
Primary Language
Please select...
English
Spanish
Chinese
Korean
Other
Other Primary Language
Employer
Child/Young Adult Info
First Name
Last Name
Gender
Male
Female
Birthdate
School
Grade
Does your child have
Individualized Family Service Plan (IFSP)
Individualized Education Program (IEP)
504 Plan
None
I Don't Know
Individualized Education Program (IEP)
Classification
Please select...
Autism
Deaf-Blindness
Deafness
Developmental Delay (Early Childhood)
Emotional Disturbance
Hearing Impairment
Intellectual Disability
Multiple Disabilities
Orthopedic Impairment (physical)
Other Health Impairment (eg. ADHD)
Specific Learning Disability
Speech or Language Impairment
Traumatic Brain Injury
Visual Impairment including Blindness
Suspected Disability
Inappropriately Identified
Unknown
Disability
Please select...
ADD
ADHD
Angelman Syndrome
Asperger's Syndrome
Asthma
Autism
Cerebral Palsy
Deaf-Blind
Developmental Disability
Down Syndrome
Dyslexia/Learning Disability
Emotional Disability
Epilepsy
Fragile X Syndrome
Hearing Impaired/Deaf
Intellectual Disability
Mobility Disability
Neurological Disability
Pervasive Developmental Disorder
Physical/Orthopedic Disability
Seizure Disorder
Sensory Processing Disorder
Speech/Language Disorder
Traumatic Brain Injury
Visual Disability/Blind
Multiple Disability
Other
Unknown
If your child has more than one disability,
please include them in the notes section.
Notes
Relationship Info
Relationship to child
Please select...
Parent
School educator/administrator
Service provider
Other professional
Foster parent
Youth/Student
Other relative
School role
Please select...
General Education Teacher
Special Education Teacher
Administrator
Additional Information about relationship
Request Info
Please describe what you would like to discuss with a family educator
I am concerned about
Public education system
Non-school systems or concerns
Information and/or referral
Other
My Specific Areas of Concern are
504
Assistive Technology
Behavior Supports/ Issues
Clarification of Rights
Diploma Options
Early Intervention
Emergency Svcs./Crisis Intervention
Harassment/Bullying
Individualized Education Program (IEP) Compliance
Meeting Prep: Individualized Education Program (IEP)
Meeting Prep: Impartial Hearing
Meeting Prep: Mediation
Meeting Prep: Resolution Session
Other
Post Secondary Education/ College
Preschool
Process/Guidance (Education)
Safety Transfer
School Placement: High School
School Placement: Kindergarten
School Placement: Middle School
School Placement (request to change)
Transportation
Turning 5
My Specific Areas of Concern are
Accessible Housing/ Adaptation
Conservatorship
Equipment
Guardianship
Navigating Services: Medicaid Waiver
Navigating Systems: Care Coordination
Navigating Systems: Housing
Navigating Systems: OPWDD
Other
Public Benefits (food stamps/rent asst)
Residential Programs (After 21y.o)
Respite
SSI/SSDI
Vocational/Employment Training
My Specific Areas of Concern are
Camp/Day
Camp/Sleep Away
Child Care
Evaluation
Financial Assistance
Health/Medical
Legal Services
Mental Health Svcs.
Other
Parenting Skills Training
Recreation/After School
Support Group
Therapies (ABA OT PT SP/L etc)
Tutoring
How did you find out about us?
Referral from school
Referral from non-school professional
DOE form/letter
Have received direct assistance from INCLUDEnyc/RCSN before
Attended INCLUDEnyc event: workshop, fair, etc.
Internet search
Referred by other organization
Word of mouth: parent
Word of mouth: other
None of the above